Ophthalmology and Optometry Coding Alert

Ophthalmologists keep up to date with the latest research. They are akin to physicists when it comes to understanding science. And they are working very hard to stay on top of managed care and Medicare rules. But how important is it for an eye specialist to know about coding?

The answer is: very important, according to our sources. Only the doctor knows what hes doing in the exam room, explains Pat Perry, office manager for Clemson Ophthalmology, a solo provider based in Clemson, SC. Only the doctor knows what level E/M code to document and use.

The ophthalmologist has a major role in learningand understandinghow coding works, says Perry. Our doctor made himself do it, she reports. And I cant tell you how helpful it is. Perrys doctor has manufactured his own help tool sheets, which he uses to assist in determining what level to use (her practice uses the 1997 E/M documentation guidelines). This doctor made himself savvy enough to make the system work for him, notes Perry.

Any ophthalmologist who doesnt want to get involved in coding will need to shell out the bucks to have someone be his scribe, opines Perry. The scribe will have to be someone who knows the levels of E/M services, and who can be right on his tail all the time, she asserts.

Catching Problems

Cassy Thrasher, who is in charge of billing and accounts receivable for Atlantic Ophthalmology in Beaufort, SC, agrees. Our doctor does all his own coding, she says. But she stresses that it is important for a coding person to check over the documentation. I get involved when there are special circumstances. For example, if the claims filerwho knows what to look forthinks a modifier is necessary, she will tell Thrasher, who will review the claim and, if necessary, complete the coding.

This happened recently with the -57 modifier (decision for surgery), Thrasher explains. We hadnt been using it, she says. Then we realized that there were a lot of denials when patients came in for their six-month or one-year checks, she says. During these checks, the ophthalmologist decided that surgery was needed, either that day or the next day. Insurance would bundle the two things together, and call it pre-op, she says. So I notified the claims filer to watch out for these, and I add the -57 modifier. That way the six-month or one-year checkup is recognized as a separate service and is paid accordingly.

Medical Necessity and Diagnosis Codes

Its not only the procedure codes that are important for ophthalmologists to know, its the diagnosis codes, opines Perry. Thats because under Medicare, the intent of the visitthe reason the patient is there is what determines medical necessity, she adds. If a patient comes in who is complaining of blurry vision, we code for that symptom, she says. Without the patient complaint, even if the ophthalmologist, upon examining the patient, finds a cataract, the visit is not billable, she notes. In other words, if a patient comes in merely asking to have his or her eyes checked, but doesnt have a complaint, and, in examining the eyes, the ophthalmologist discovers a cataract, you cant bill for the visit under Medicare. If, however, the patient complains of blurry vision, and the ophthalmologist finds a cataract, the blurry vision complaint would be the primary diagnosis code, and the cataract would be the secondary diagnosis code, says Perry.

So its very important to listen carefully for a complaint from the patient. The ophthalmologist can help determine if there is a complaint by asking the patient to be very specific about symptoms, and documenting the patients response. The technicians can help you with diagnosis coding if they are trained in communicating with the patients, says Perry. Our technicians try to find out what the symptoms are, she says.